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12080193 CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: 19978 PORTAL PLZ CONTRACTOR:KRT INC PERMIT NO: 12080193 OWNER'S NANIF,: CHRISTOPHER ANTHONY 1 AND BETT 21001 SAN RADION VALLEY BLVD DATE ISSUED:08272012 OWNER'S PI ZONE: 4159649781 SANRAMON,CA 94583 PHONF.NO:(925)556-0632 ❑ LICENSED COYFRA(TFOR'S DIiCLARATIIO-N BUILDING PERMIT INFO: BLDG r ELECT r PLUMB rl License Class1Lie.N �� 40 0 NIECII r RESIDENTIAL Ci COMMERCIAL K r Contractor 2(t —E� L Date hereby affirm(hat I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE&REPLACE CLERESTORY WINDOW TO (commencing with Section 7000)of Division 3 of the Business S Professions FACILITATE Code and that my license is in full force and effect. RIiftOOFING 1 hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Sq.FI Flnnr Area: Valuation:$1500 permit is issued. API'LICAN'FCERTIpICA'1'10\ APN Number:36945003.00 Occupancy Type: I certify that 1 have read this application and state that the above information is correct.1 agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes, (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature CL��Datc� _!1-y Issued by: �EA/1/ %�/� Date:�j 'a�-/2 ❑ OWNER-RUILDER DECLARATION �/ RE-ROOFS: hereby affirm that 1 am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner ollhe property,or my employees with wages as their sole comp_nsation, inspection. will do the work,and the structure is not intended or offered for sale(Scc.7044, ' Business d Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business B:Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER hereby affirm under penalty of perjury one of the following three declarations: IIA''/-ARDOUS MATFRLM S DISCLOSURE I have and will maintain a Certificate of Consent Ioself-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code.for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health S Safety Code,Sections 25505.25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ileallh S Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should 1 store or handle hazardous material. Additionally,.should 1 use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Qualify Management District I will I certify that in the performance of One work for which this permit is issued,1 shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Ileallh S Safety Code.Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must Osvn�yq Pnze cola forthwith comply with such provisions or this permit shall be deemed revoked. 111--V�{� ° =- Dater 12-, CONSTRucf1ON LENDING AGENCY APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of mark's correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCI I ITFCl"S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Scction 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional CONSTRUCTION PERMIT APPLICATION go G� COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING' DIVISION Ic�1 10300 TORRE AVENUE •CUPERTINO,CA 95014-3255 \� �/ V CUPERTINO 2 (408)777-3228• FAX(408)777-3333•buildin° uoertino.ora /// ❑NEXV CONSTRUCTION ❑ ADDITION ❑ ALTERATION/Ti ❑ REVISION/DEFERRED ORIGINAL PERMIT p PROIECi ADDRESS ` APNM 00 O%VNERNAME 1 U ( Ov PHONEvelQ YGI? S�' STREET ADDRESS CTIY,STATE,2IP c �k. o c� Soy mo1� I Cw q4� N CONTACT NAME / PHONE E NAB. •JUR1C G. �.�'J'Q. STREET ADDRESS CITY,STATE.ZIP FAX XOWNER ❑ OW'NERRUILDER ❑ OW'NERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NANIE K I Ito LICENSE NUMBER -7S9-1?09 LICENSETYPE v BUS.LIC 13o`!- a� COMPANY NAME KR T Yl-Iv6— 6NIAIL J F X 1 lam— � S5 06 STUi oos s e,9eUa 1/gtck�(3L,/p A� C Y,S tIA)P OAMon ca "4583 °s ARCHTTEC(ENGINEER NAME LICENSE NUNIBER BUS.LIC I COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORN EM0✓9 Pli9 C-IF -z-Ai D 0 I — ' LL •r0 Yu — 'Dow leo /G aF LZIc-/ _ EXISTING USE PROPOSED USE CONSTR.TYPE I ISTORIE$ USE TYPE OCG SQ.FT. VALUATION(5) CXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA TOTAL BATHROOM KITCHEN OTHER REMODEL AREA REMODELABEA REMODELAREA PORCH AREA DECK AREA TOTAL DECNPORCH AREA GARAGEAREA: DETACH ❑ATTACH /DWELLING UNITS: IS A SECOND UNIT YES SECOSDSTO—RI' YES BF.INGADDED'. [:]NO ADDITION` ❑NO n PRE-APPLICATION ❑YES IFYES,PROVIDECOPI.LOF E IS THF.BLDG AN ❑YE$ RECEI B *r '" a TOTAL VALUATION: PLANAINGAPPLI [],NO PLANNING APPROVAL LEI-RI EICIILER IIONIE' NO By my signature below,I certify to each of the following: I am the property owner or authorized ptento act on the property owner's behalf. I have read this application and the information 1 have provided is correct. I have read the Description of Work and veIN-it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I authorize rep 'res of Cupertino to enter the aboveIidentified property for inspection purposes. Signature of ApplicanVAgenC CVC ,Date: SUPPLEMENTAL INFORMATION REQUIREDa'3' �+ n Tin PI.AX CHECR TI'PE-'?.' T +Sri NiiMTROMNG SLIP New SFD or Multifamily dwellings Apply for demolition Permit for ON R THGCOUXTER1 ❑ BUB.DING PLAN RE\IE'Wft existing building(s). Demolition permit is required prior to issuance ofbulldingE w -n 1 ^r r permit for new building. EXPRESSPIUN F4. -r may, h❑ XIN N.AE\TEN ."'",'•. '7 _Commercial Bldgs: Protide a completed hazardous btaterials Disclosure ❑PUBIC W ORRR5S'❑.STnXc\Row. },ems+. Tom if any Hazardous Materials are being used as pan of this project. . :❑ LARCE'F 5 ts3,.-raV'.� ❑ FTREDFrr ��'[ T _Copy of Planning Approval Letter or Meeting with Planning prior to - submittal of Building Permit application. t \rL C,R�sy,a. ,Ste_'T�$[, ❑TSANITA Ry �RyDISTRICT ; 4P �J' r'ti alFVp t❑ 'E\'\IRON\IE,\T AI,'HEAI,THV....i BldgApp_2011.doc revised 06121111 i